low level paraplegia
TRANSCRIPT
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Low level Paraplegia
Definition:
It is paralysis or weakness of both lower-limbs due to bilateral pyramidal tract lesion in thespinal cord(T12 to L4).
Clinical Picture of Focal Paraplegia
A.At the level of the lesion:1. Vertebral manifestations: Only present if the cause is vertebral.
- Localized pain or tenderness. - Localized deformity or swelling.
2. Radicular manifestations: Only present in extra-medullary causes.
a) Posterior root affection:
- Early pain in the back referred to the distribution of the affected root.
- Later, there is hypoesthesia or anesthesia in the dermatome supplied by the
affected root.
b) Anterior root affection: localized L.M.N. weakness in the muscles supplied by the
affected root.
B. Below the level of the lesion: (cord manifestations):
1. Motor Manifestations: They depend on whether the cause of the lesion is acute o
gradual.
a) If the cause is acute (inflammation, vascular or traumatic), the paraplegia passes
through 2 stages:
Stage of flaccidity due to neuronal shock:
there is sudden paralysis of the lower limbs, associated with complete loss of tone
and absence of reflexes.
Stage of spasticity due to recovery from the neuronal shock:
On recovery from the shock stage, the full picture of U.M.N.L. will be estab-lishedincluding: hypertonia, hyper-reflexia, positive Babinski sign & may be clonus.
b) If the cause is gradual (e.g. neoplastic): The shock stage is absent and there will
be gradual progressive weakness of LL with hypertonia and hyper-reflexia.
N.B: Piere Marie Foix testis done by firm passive plantar flexing of the toes and foot.
This will result in spontaneous "withdrawal reflex" i.e. spontaneous flexion of the
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hip, knee and dorsiflexion of the ankle if the paraplegia is passing from extension to
flexion.
2. Sensory Manifestations:
a) If the cause of the lesion is extramedullary, encroachment on the ascending tracts
at the site of lesion results in sensory level below which, all types of sensations are
diminished. There is early loss of sensation in the saddle area (S 3, 4, 5), as the sacral
fibers lie in the outermost part of the spinothalamic tracts in the cord.
b) If the cause of the lesion is intramedullary, there will be a jacket sensory loss
(hyposthetic area with normal sensations above and below it). The sensory loss is of
a dissociated nature i.e. pain and temperature sensations are lost but touch and
deep sensations are preserved;The sensations over the saddle area are preserved
(sacral spare), as the
sacral fibers lie far from the midline lesion.
3. Sphincteric Manifestations: a. In acute lesions: There is retention of urine in theshock stage, followed by precipitancy of micturition.
b. In gradual lesions: There is precipitancy of micturation which may terminate in
automatic bladder when complete transaction of the cord occurs.
* These changes start late in extramedullary lesions and early in intramedullary
lesions as the pyramidal fibers controlling the bladder centre lie medially in the cord.
4.Sexual dysfunction.
5.Impaired sympathetic outflow.
Secondary complications of SCI:
1)Spinal instability.
2)osteoporosis and renal calculi .
3)Heterotopic ossification.
4)Respiratory complications.
5)Pressure sores.
6)Autonomic dysreflexia(hyperreflexia)
7)Orthostatic hypotension.
Physiotherapeutic assessment for traumatic spinal cord injury:
A)History
1)Personal history:
Age: occurs commonly at young age.
Sex :occurs In males more than females.
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2)Present history:
Onset: sudden
Course: mainly regressive.
3)Past history:
Head or spinal Trauma
B)Examination:
1)Mental examination:
Mood and affect changes may occur.
2)Motor examination and sensory examination:
Designation of lesion level:
-Neurological level:
The most caudal level of the spinal cord with intact motor and sensory functions
bilaterally.-Motor level:
The most caudal level of the spinal cord with intact motor function bilaterally.
-sensory level:
The most caudal level of the spinal cord with intact sensory function bilaterally.
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3)Respiratory assessment
Less important in low level paraplegia as respiratory muscles are free.
Chest expansion
Breathing Pattern
Cough
Vital capacity
4)Skin Examination:
Regular skin inspection should be done and teached to the patient and the family.
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5)ADL Examination:
It must be done to determine the functional ability of the patient with cautious so as not to
stress on the fracture site.
It may be assessed by :function independence measures(FIM).
Physical therapy treatment:
Icu phase
- Respiratory management
- Posioning
- Passive range of motion exercises
- turning
respiratory management:
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Breathing Exercises
Lateral Expansion
For those patients who have some intercostal innervation
(Tl through Tl2), lateral expansion or basilar breathing
should be emphasized. Patients are encouraged to take deep
breaths as they try to expand the chest wall laterally. PTAs
can place their hands on the patient's lateral chest wall and
can palpate the amount of movement present. Manual
resistance can eventually be applied as the patient gains
strength in the intercostal muscles. Progression to a two
diaphragm, two-chest breathing pattern is desirable.
Incentive Spirometry
Another activity that can be used to improve the function of
the pulmonary system is incentive spirometry. Blow bottles at
the patient's bedside can encourage deep breathing. A meas
urement of a patient's vital capacity can be taken with a
handheld spirometer. Vital capacity is the maximum amount
of air expelled after maximum inhalation. Measurements of
the patient's vital capacity can be taken throughout rehabil
itation to document changes in ventilation (Wetzel, 1985).
Patients can also be instructed to vary their breathing rate
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and to hold their breath as a means to promote improved
respiratory function.
Chest Wall Stretching
Spasticity and muscle tightness within the chest wall can
develop. Manual chest stretching may be indicated to increase
chest expansion. The assistant can place one hand under the
patient's ribs and the other on top of the chest. The clini
cian then brings the hands together in a wringing type of
motion. The clinician moves segmentally up the chest. This
procedure is contraindicated in the presence of rib fractures
(Wetzel, 1985). Intervention 12-1 illustrates a clinician per
forming this technique.
Postural Drainage .
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back. Percussion is applied bilaterally, directly below the scapulae.
Postural drainage with percussion and vibration may be nec
essary to aid in clearing secretions.
Coughs
Coughs are classified into three deterrent categories, based
on the amount of force the individual is able to generate.
Functional coughs are those that are strong enough to clear
secretions. weak functional coughs produce an adequate
amount of force to clear the upper airways. Nonfunctional
coughs are ineffective in clearing the airways of bronchial
secretions (Wetzel, 1985).
Assisted Cough Techniques
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Percussion, vibration and shaking of the chest wall are used to improve secretion
clearance. All these interventions can potentially move the spine. For this reason they
should be used cautiously in acutely-injured patients and only with medical
approval.
Suctioning is used to move secretions from the trachea. However, this is an unpleas-
ant and invasive technique which should only be used when other interventions
fail.
cheostomies can be used. These provide direct tracheal access and are a more com-
fortable and effective way of suctioning secretions. Minitracheostomies cannot,
however, be used for other purposes (e.g. to provide invasive ventilation).
Suctioning can elicit a vagal reflex response which can cause a cardiac arrest. This
is due to loss of supraspinal control of the sympathetic nervous system and is precipi-
tated by hypoxia
Passive movement and stretching
Positioning:
The supine position (Fig. 4.1A)
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When supine, the patient is positioned in the following way.
Lower limbs
Hips extended and slightly abducted
Knees extended but not hyperextended
Ankles dorsiflexed
Toes extended.
One or two pillows are kept between the legs to maintain abduction
and prevent pressure on the bony points, i.e. medial condyles and
malleoli.
Upper limbs (for patients with tetraplegia)
Shoulders adducted and in mid-position or protracted, but not
Retracted
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Elbows extended; this is particularly important when the biceps
is innervated and the triceps paralysed. If the biceps is overactive,
extension can be maintained by wrapping a pillow round the
forearm, or by using a vacuum splint or making an individual
splint of suitable material.
Wrists dorsiflexed to approximately 45
Fingers slightly flexed
Thumb opposed to prevent the development of a monkey hand,
which is functionally useless.
The arms are placed on pillows at the sides. The pillows should be
high enough under the shoulders to ensure that the shoulders are not
retracted, when damage to the anterior capsule can occur. If the
shoulders are painful and protraction is required, a small sorbo
wedge can be placed behind the joint on either or both sides. If neces-
sary, two pillows should be used under the forearms and hands, as
it is important that the hands are kept higher than the shoulders to
prevent gravitational swelling in the static limbs.
The side-lying or lateral position (Fig. 4.1B)
When lying on the side, the patient is positioned in the following
manner.
Lower limbs
Hips and knees flexed suffi ciently to obtain stability with two
pillows between the legs and with the upper leg lying slightly
behind the lower one
Anklesdorsiflexed
Toes extended.
Upper limbs
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Lower arm shoulder flexed and lying in the trough between
the pillows supporting the head and thorax to relieve pressure
on the shoulder
Elbow extended
Forearm supinated and supported either on the arm board
attached to the more sophisticated beds or on a pillow on a table
Upper arm as in the supine position, but with a pillow
between the arm and the chest wall.
For the hipflick position.
In patient phase
The same as icu plus
Dermatome
L1 Upper 1/3 front of thigh
L2 Middle 1/3 front of thigh
L3 Lower 1/3 front of thigh
L4 Antero-lateral aspect of thigh, front of knee, antero-medial aspect of leg, medial aspect
of foot and big toe
L5 Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot and middle 3
toes
S1 Postero-lateral aspect of thigh and leg, lateral 1/3 of dorsum of foot and little toeS2 Posterior aspect of thigh, leg and sole of foot
S3, 4, 5 Anal, peri-anal and gluteal region (saddle shaped area)
3- Training for postural control
The terms
balance,,equilibrium and and
postural control are used
as as synonyms for
concept of the mechanism
by which the human body
prevents itself from falling
or loosing balance
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POSTURAL CONTROL
controlling the bodys position in space
for the dual purposes of stability stability and orientation
POSTURAL ORIENTATION
This involves
The ability to maintain the
appropriate alignment between
body segments
The appropriate relationship
between the body and the
environment
Requires establishing a vertical
orientation to counteract the
forces of gravity.
Creates a reference frame for
perception and action with. respect to the external world.
POSTURAL STABILITY
This involves
Maintaining the bodys centre of
mass within boundaries of space, ,referred to as referred to as stability limits.
Stability limits are boundaries of
an area of space in which the body can maintain its position
without changing its base of support
impairments of postural control in low level para plegia secondary to weakness and sensory disturbance
Good trunk control
Total control of upper extremities
Partial to full control of lower extremities
Imparirment of pelvis control
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Impairment in standing control
Impairment in locomotion and gait
A pelvis control
Kneeling: Prerequisite Requirements
Prior to the use of kneeling as an activity, several impor-
tant requirements for assuming the posture need consider-
ation. Full hip flexor ROM is necessary: if limitations
exist. the patient's ability to achieve the needed hip exten-
sion will be compromised. Sufficient strength'of the trunk
and hip extensor muscles is necessary to keep the head
and trunk upright and the hips extended. This is partiCLI-
larly important given the relative anterior instability in-
herent in the posture. Although kneeling provides an im-
pOltant opportunity for improving posture and balance
control. adequate static postural control (ability to keep
the COM over the BOS) is needed for initial maintenance
of the upright posture.
A Kneeling, Assist-toPosition
ACTIVITIES, STRATEGIES, AND VERBAL CUES FOR KNEELING,
ASSIST-TO-POSITION FROM BILATERAL HEEL-SIDING
Activities and Strategies For assisted movement transi-
tions into kneeling, both the patient and the therapist are ini-
tially positioned in heel-sitting facing each other (Fig. 5.2A).
The therapist places one hand on the posterior upper trunk
passing under the axilla: the opposite manual contact is on
the contralateral postel;or hip/pelvis. These hand placements
allow the therapist to assist with lifting the trunk into the up-
right position as well as with moving the patient's hips toward
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extension. The patient's hands are supp0l1ed on the therapist's
shoulders, which assists in guiding the upper trunk in the de-
sired direction of movement. The patient and therapist then
move together into a kneeling position.
Position/Activity: Kneeling, Weight Shifting
Weight shifting in kneeling is a closed-chain exercise that
involves motions in which the distal part (knees) is fixed
while the proximal segment (pelvis) is moving. Weight-
shifting activities provide the important benefit of promot-
ing the simultaneous action of synergistic muscles at more
than one joint. In addition, the joint approximation and stim-
ulation of proprioceptors further enhance joint stabilization
(cocontraction). Since the kneeling posture must be stabi-
lized while moving. weight shifting also improves dynamic
stability
Half kneeling
General Characteristics
The posture is more stable than kneeling. Half-kneeling
iJl\oh e, head. trunk. and hip muscles for upright postural
control. The head and trunk are maintained on the vertical in
midline orientation with normal spinal lumbar and thoracic
cur\'es. The peh'is is maintained in midline orientation with
the hip fully extended on the posterior stance limb. As with
kneeling. static postural col/trol is necessary for the main-
tenance of upright posture. Dynamic postural control is
necessary for control of movements performed in the posture
(e.g.. weight shifting or reaching). Reactive balance control
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is needed for adjustments in response to changes in the COM
(perturbation) or changes in the SUpp011 surface (tilting). An-
ticipatory balance control is needed for preparatory postural
adjustments that accompany voluntary movements.
Clinical Notes:
o Holding in the posture and weight-shifting activities in the
half-kneeling position provide an early opportunity for par-
tial weightbearing on the forward foot; the position can
also be used to effectively mobilize the foot and ankle
muscles (e.g., for the patient with ankle injury).
. As in kneeling, prolonged compression provides inhibitory
influences on the stance-side quadriceps; there is no in-
hibitory pressure on the quadriceps of the forward limb.
o The asymmetrical limb positioning (one stance limb
and one limb forward with foot flat) can be used to dis-
associate (break up) symmetrical limb patterns. Half-
kneeling is a useful actiVity for the patient with spastic
diplegia (cerebral palsy).
o As with kneeling, half-kneeling may be contraindicated in
some patients, such as individuals with rheumatoid or os-
teoarthritis affecting the knee, patients with knee joint in-
stability, or patients recovering from recent knee surgery.
Position and \cth it~ : Half-Kneeling. Assist-to-Position
Assist-to-position mo\ement transitions into half-kneeling
can be effectivel) accomplished from a kneeling position.
This movement transition is an important lead-up skill to in-
dependent floor-to-standing transfers.
b-Standing control
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Normal Postural Synergies
Normal postural strategies for maintaining upright stability
and balance include:
~ Ankle strategy involves small shifts of the COM by rotat-
ing the body about the ankle joints: there is minimal
movement of the hip and knee joints. Movements are
well within the LOS (Fig. 7.3A).
- Hip strategy involves larger shifts of the COM by flexing
or extending at the hips. Movements approach the LOS
- Change ofsupport strategies are activated when the COM
exceeds the BOS and strategies must be initiated that
reestablish the COM within the LOS. These include the
stepping strategy, which involves realignment of the BOS
under the COM achieved by stepping in the direction of the
instability. They also include UE grasp
strategies. which involve attempts to stabilize movement of
the upper trunk. keeping the COM over the BOS.
STANDING A PATIENT WITH A
KNEEANKLEFOOT ORTHOSIS
Standing between parallel bars
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Exercises in standing
As control is gained over the upper thorax, the therapist can place
both hands around the hips to support only the pelvis. The hands
are placed along the iliac crest, with the fingers over the anterior
superior iliac spine. With the hands in this position, the therapist
can pull the pelvis back with her fingers (Fig. 13.6A), push it forward
with the heel of her hand (Fig. 13.6B), give pressure downwards
(Fig. 13.6c) or lift upwards. In this way, the therapist has complete
control of the patient and can assist or resist movement in any
direction.
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Balance exercises
Watching his position in the mirror, the patient is taught to:
hold, move out of and regain the correct posture
maintain balance whilst lifting one hand off the bar (Fig.
13.4D). Progression is made by moving the arm in all directions,
and later by repeating this with the eyes closed
move both hands forwards and backwards along the bars.
Exercises for strength and control
Before commencing gait training, the patient must learn to tilt his
pelvis by using latissimus dorsi, and to become aware of the degree
of control he can achieve with this compensatory mechanism.
Pelvic side tilting
To hitch the left leg, place the left hand on the bar only slightly in
front of the left hip, and the right hand about half a foot length
further forward. Keeping the elbow straight, press fi rmly down on
the left hand and depress the shoulder.
The leg must be lifted upwards and not forwards.
To lift both feet off the ground and control the pelvis
Place both hands on the bars slightly in front of the hip joints. Push
down on the bars, with the elbows straight, and depress the shoul-
ders. To gain control of the pelvis, the patient should practise holding
himself at both full and partial lift, rotating the trunk and tilting the
pelvis with the feet lifted off the ground.
Resisted trunk exercises
For greater effi ciency in balance, strength and control, resisted trunk
exercises in the standing and lifting positions and resisted hitching
are also given.
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Passive stretch in standing
Where strong spasm in the hip flexors and abdominal muscles pre-
vents the patient from assuming the erect posture, a passive stretch
can be given. The therapist gives fi rm pressure forwards with her hip
against the patients sacrum, and with her hands pulls backwards
over the front of the shoulder joints.
If the position is maintained for a few moments the spasticity
usually relaxes and the patient is able to maintain his balance.
Transfer training
To transfer from chair to crutches
An unaided exit from a chair is essential if crutch walking is to be
functional. There are three techniques used to get into and out of the
chair with crutches:
forwards technique
sideways technique
backwards technique.
All three methods are taught where possible, and the patient chooses
that which he finds easiest.
Forwards technique
Severe abdominal and/or flexor spasticity which prohibits the neces-
sary hyperextension at the hips, or excessive height, may prevent a
patient accomplishing this technique. When the patient is well over
average height with the extra length primarily in the legs, the elbows
are higher than the shoulders with the crutches in position for the
lift. Latissimus dorsi and triceps are thus at a mechanical disadvan-
tage and a balanced lift is impossible.
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The therapist
The therapist stands in front of the patient astride the legs and ready
to give support with her hands around the scapula region (Fig.
13.9AD).
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Action of the patient
1. Check the position of the chair and swing away or remove the
footplates. During early training, when the weight distribution
may be incorrect, a feeling of stability is given if the chair is
backed against a wall.
2. Sit well back in the chair (Fig. 13.10A).
3. Place the crutches midway between the front and rear wheels,
level with each other and equidistant from the sides of the
chair (Fig. 13.10B). To avoid rotation during the lift, the
position of the crutches must be accurate.
4. Lean forward over the crutches and balance.
5. Lift on the crutches, adducting and extending the shoulders.
6. The feet are lifted backwards, and as the weight goes onto
them, hyperextend the hips and retract the shoulders (Fig.
13.10C).
7. When balanced, move the crutches forward and assume the
correct standing position (Fig. 13.10D).
To sit down, reverse the procedure, as in Figures 13.10DA.
If the physical proportions of the patient are suitable, an alterna-
tive method is shown in Figure 13.10E. The short patient reaches
back with his hands, releases the crutch handles and grasps the arm-
rests. Such patients may be able to stand up in the same way. To
prevent trauma, which could result in haemorrhage and bursa forma-
tion, sitting down should be done slowly without bumping on the
chair.
Sideways technique
Some patients of below average height are able to get out of the chair
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using one crutch and an armrest:
1. Put the left arm through the forearm support, position the left
crutch and grasp the armrest.
2. Turn through 45 towards the left armrest.
3. Place the right crutch in front and to the left of the midline of
the chair.
4. Lift on both arms (Fig. 13.11A, B).
5. With the weight on the feet, balance on the right crutch and
grasp the left crutch handgrip.
Reverse the procedure to sit down.
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Backwards technique
The therapist stands in front of the patient ready to control the pelvis
or legs as necessary.
To turn to the left:
1. Cross the right leg over the left (Fig. 13.12A).
2. Lift the buttocks to the right side of the chair (Fig. 13.12B).
3. Turn the trunk to the left, moving the left hand to the right
armrest and the right hand to the left armrest (Fig. 13.12C).
4. Push on both armrests to stand (Fig. 13.12D) facing the chair.
5. Hitch the feet to the left (Fig. 13.12E).
6. Put each hand through the crutch forearm supports and return
to holding the armrests (Fig. 13.12F).
7. Grasp the handgrips in turn.
8. Walk backwards away from the chair (Fig. 13.12G).
Reverse the procedure to sit down.
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To get down and up from the floor onto crutches
Crutches to floor
The therapist stands behind the patient and controls the pelvis, feet
and legs, as necessary:
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1. From the standing position on the mat (Fig. 13.14A), walk the
crutches forward one by one (Fig. 13.14B) until the hips and
trunk are suffi ciently fl exed for the outstretched hand to reach
the floor.
2. Balance on the right crutch, release the left crutch and put the
left hand on the fl oor (Fig. 13.14C).
3. Balance on the left hand, release the right crutch and put the
right hand on the fl oor (Fig. 13.14D).
4. Walk forward on the hands until lying prone (Fig. 13.14E).
Floor to crutches
The therapist may need to assist the patient to get the weight over
his feet initially:
1. Lying prone, make sure the ankles and toes are dorsiflexed so
that the feet are vertical (Fig. 13.14F).
2. Position the crutches, tips forward, well in front of the body
and put both forearms through the forearm supports.
3. Press up on the hands, and at the same time use the abdominal
muscles to pull the pelvis towards the hands and so prevent the
legs being pushed backwards.
4. Maintaining the action of the abdominal muscles, walk the
hands towards the feet, trailing the crutches (Fig. 13.14G) until
the weight is over the feet (Fig. 13.14H).
5. Balance on the left hand, grasp the right crutch handgrip and
place the crutch on the fl oor (Fig. 13.14I).
6. Balance on the right crutch and take hold of the left
crutch in a similar manner. Balance on both crutches (Fig.
13.14J).
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7. Walk the crutches towards the feet until standing erect (Fig.
13.14K).
To get out of a car onto crutches
1. Turn to face the open door and lift the legs out of the car.
2. Lock the knee joints.
3. With the window open, use the window ledge and the back of
the seat, or the seat and a crutch, to lift into standing.
4. Balance with the hips hyperextended and take hold of each
crutch in turn.
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Gait training
There are three types of gait used:
swing-to gait
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four-point gait
swing-through gait.
Controlled walking is achieved only through perseverance, perfect
timing, rhythm and coordination. The patient is taught always:
1. to move the hands first
2. to walk slowly and place his feet accurately
3. to take the weight through the feet and so ensure that the
hands can relax between each step
4. to lift the body upwards and not to drag the legs forwards.
An accurate technique must be achieved in bars if crutch walking is
to be successful.
Where it is anticipated that the patient will become an accom-
plished walker, it is usual to commence training with the four-point
gait. It is easier to learn to use the latissimus dorsi muscles at first
separately and then together than vice versa.
GAIT TRAINING IN THE BARS
Swing-to gait
This is the universal gait because it is both the simplest and the safest.
All patients with lesions above T10 are normally taught this gait
first.
The therapist
The therapist stands behind the patient with her hands over the iliac
crests. Assistance is given to lift, to control the tilt of the pelvis and
to transfer weight as necessary (Fig. 13.6AC).
Action of the patient
1. Balance in the hyperextended position.
2. Move the hands, either separately or together, forward along the
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bars approximately half a foot length in front of the toes.
3. Lean forward, with the head and shoulders over the hands (Fig.
13.6D), and lift the legs, which will swing forward to follow the
position of the head and shoulders. The step is short and the feet
must drop just behind the level of the hands (Fig. 13.6E). To
achieve this, the lift must be released quickly, otherwise the feet
will travel too far and land between or in front of the hands.
When on crutches, it is unstable and therefore dangerous to have
the feet and hands in line. It must therefore be avoided in the
bars. The swing-to gait is a staccato gait with no follow through:
lift and drop.
The patient should also be taught to swing backwards along the
bars.
To turn in the bars
The turn is achieved in two movements by turning through 90 each
time.
To turn to the right:
1. Place the left hand forward about a foot length along the bars and
the right hand either level with or a little behind the trunk.
2. Lift and twist the shoulders and upper trunk to the right. The
feet land facing the bar to the right (Fig. 13.7A).
3. Balance in this position and move the left hand across to the
right bar (Fig. 13.7B).
4. Twisting the upper trunk to the right, place the right hand on
the opposite bar.
5. Lift the feet round to a central position between the bars (Fig.
13.7C).
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Benefits of Body Weight Support (BWS) and a Treadmill
Locomotor interventions may be implemented earlier
in the episode of care (compared to more conventional
approaches).
Loading of the UEs is minimized or eliminated owing to
maximal loading of the LEs.
LE loading can be varied based on the patient's ability
to support weight.
Compensatory movement strategies are reduced or
eliminated.
Learned nonuse may be eliminated secondary to
weightbearing and "forced" stepping movements of
more involved segments.
Normal gait kinematics and phase relationships of the
full gait cycle are promoted (e.g., limb loading in
midstance; unweighting and stepping during swing).
The fear of falling is reduced or eliminated.
I :e- and intra-limb locomotor timing and rhythm can
be Dromoted without the demands of supporting the
, 11 body weight.
R m'c input from the constant speed of the TM
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he ps 0 reestablish or reinforce coordinated reciprocal
LE patterns.
Using greater BWS and 10wTM velocity, gait
deviations may be addressed early.
Dynamic balance training can be practiced by
decreasing BWS and increasing the TM speed.
Sensory inputs facilitate muscle activation.
Coordinated kinematics of the trunk, pelvis, and limbs
specific to the locomotor task are promoted.
Walking speed and distance improve.
Muscular and cardiovascular endurance improves.
GAIT USING FUNCTIONAL ELECTRICAL STIMULATION
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(FES) STANDING SYSTEMS
For the past 30 years, experiments have been undertaken to enable
patients to walk using electrical stimulation of the relevant muscles.
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Surface, nerve cuff and deep muscle electrodes have been used. FES
is applied to the intact lower motoneurone pathways and is therefore
only suitable for upper motoneurone paralysis, as with stimulation
of the phrenic nerve (Ch. 5). Initially, FES is used to improve the
condition and bulk of the paralysed muscles. When the state of the
muscles has improved, electronic implants can be used to activate
muscles in functional sequence. Interestingly, 50 years ago Sir Ludwig
Guttmann showed that muscle bulk could be improved in rabbits
(Guttmann & Guttman 1942) and later in humans using galvanic
stimulation (Guttmann & Guttman 1944).
Surface stimulation
Root stimulation gives access to the whole motor output, whilst
surface stimulation reaches only part of it. Usually the gluteal and
hamstring muscles are stimulated for standing, and quadriceps and
the flexor withdrawal response for walking. To stimulate more
muscles is impractical as it is too time-consuming. Surface stimula-
tion is wasteful of current and requires assiduous attention to skin
care, and the stimulation varies with movement of the limbs (Rushton
Three types of implanted electrodes are used:
Percutaneous wires are inserted through the skin and focused on a
motor point. Any number of wires may be used. Formal surgery is not
required and the wires are inserted easily by a practised operator.
This procedure has a high risk of electrode failure and a high
incidence of infection. Cosmesis is unacceptable (Barr et al 1995).
The nerve cuff electrode is placed around peripheral nerves in a
formal surgical procedure.
The epimysial electrode (disc type of electrode) is placed near the
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motor point of large muscles. Less dissection is required than for the
cuff type but multichannel lower limb systems still require extensive
surgery and the cabling also has to be implanted in the limb. As cable
connectors tend to fracture, further surgery is often required.
A sacral anterior root stimulator implant (SARSI) has been widely
used to restore bladder control in male and female patients and erec-
tile function in male patients (Brindley & Rushton 1990). A lumbar
anterior root stimulator implant (LARSI) has been used to stimulate
lumbar and sacral roots (L2S2) to restore lower limb function in
two patients. These systems are now commercially available, as are
some surface and upper limb motor locomotor systems.
Stringent criteria are necessary for the selection of patients for any
FES system, which will include psychological as well as physical
assessments. For example, joints must have full range of movement
and be free of osteoporosis and the patient must be physically fit, as
energy consumption is high. Patients gain the usual benefits from
standing and walking with these systems, and Jaeger et al (1990)
found psychological benefi ts also, in that the patients self-esteem and
confi dence appeared to increase. To use a surface system long term
is impractical, but surface stimulation as a non-invasive means of
assessment and training is necessary for an implant system (Barr et
al 1995). Both systems are useful and in many ways complementary
FES does not restore functional gait. It is a form of exercise and
remains experimental. Whatever the technique used, walking speed
is slow and, together with energy consumption, is a limiting factor.
Major technical problems continue to be encountered, for example
in the selection and control of stimulation, failure of equipment and
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muscle fatigue.
To replace the intricate mechanism of normal gait is an enormous
task. It is not surprising that progress is slow. Research continues in
many centres worldwide.
In a study to examine the safety of FES, Ashley et al (1993) found
evidence to suggest that there was a danger of autonomic dysreflexia
during treatment in patients with lesions above the splanchnic
outfl ow, i.e. above T6. Extra caution should therefore be employed
with these patients.
Hybrid Assistive Limb 5
While this device has a long list of tasks that will greatly impact fields across all professions, it is being looked at in
hospitals and in medical care for patients who are suffering from illness that make them weak and unable to perform
daily tasks. It is also being used for workers in facilites to help lift items (or humans) that are overweight.
This device is currently on the market, but the thing that will most certainly revolutionize modern medicine which is still
in development is cognitive responses, in the hopes that one day wheelchair-bound individuals may be able to walk.
Lokomat
This leads to an intensive rehabilitation regiment, which dispite the patients hard work can produces limited results.
This is why researchers in Switzerland designed Lokomat, which combines medical and engineering approaches to help
patients regain mobility faster, with less pain. The Lokomat uses a robot to automate treadmill training, giving patients
longer and more frequent sessions and resulting in a faster and improved return to mobility. The robot intelligently
adapts its behavior to the patients individual capabilities.
The walking with Lokomat is said to improve pelvis and hip actuation as the walking is more natural, and the virtual
training environments can increase patients motivation and engagement.
Gait training in different environments
Walking Surfaces
Practice walking on a variety of indoor and outdoor
surfaces.
Indoor surfaces: tile, linoleum, low- and high-pile
carpet, and hardwood and laminate flooring
Outdoor surfaces: sidewalks, concrete, gravel,
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asphalt, and grassy terrains
Stair Climbing
Practice stair climbing using a handrail; progress to
stair climbing without the use of a handrail.
Practice stair climbing one step at a time; progress to
step over step; alter requirements for step height and
number of steps.
Obstacles
Practice walking while avoiding or contending with
obstacles in the environment such as the following:
Walking over and around a static obstacle course
created with objects of varying heights and widths
(e.g., step stool, chair, cans, yardstick, stacking cones,
books, and so forth); altering requirements for foot
clearance, step length, step time, and walking
speed
Walking with dynamic (moving) obstacles in the path
(e.g., revolving door, elevator, or escalator)
Walking on varying paths (e.g., changing environment)
Walking with two individuals navigating the same
obstacle course (collision avoidance)
Slopes or Ramps
Practice walking on ramps and slopes of varying
heights.
Gradual incline: using smaller steps
Steep incline: smaller steps using a diagonal, zigzag
pattern (step length decreases with increasing slope
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Requirements for navigating slopes or ramps include
the following:
Descent is associated with increased knee flexion
(stance) and increased ankle and hip motions (s ' g;
during descent, peak moments and powers are
higher at the knees.
Ascent is associated with decreased speed, cadence,
and step length.
Open Environments
Practice walking in busy, open, community
environments (e.g., a busy hallway, hospital lobby,
shopping mall, or grocery store).
Practice finding solutions to real-life functional
problems, such as the following:
Pushing or pulling open doors
Pushing a grocery cart
Car transfers: getting into and out of a car
Getting on and off a bus or other public
transportation vehicle
Carrying a bag of groceries
Practice walking and traversing unfamiliar routes and
unfamiliar places.
Practice stepping up and down curbs.
Time Requirements
Practice walking with anticipatory timing requirements,
such as the following:
Crossing at a stoplight
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Moving on and off moving walkways
Moving on and off an escalator
Walking through automatic revolving doors
Visual Conditions
Practice walking in varying visual conditions, such as
the following:
Full lighting with progression to reduced and low
lighting
With dark glasses to alter visual conditions
Varied lighting conditions (e.g., outside to inside
lighting)
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Four-point gait
This gait is the slowest and most difficult of all and is only achieved
on crutches by accomplished walkers. It facilitates turning and
manoeuvring in confi ned spaces. It also provides an excellent training
exercise in strength, balance and control.
The therapist. The therapist holds the pelvis in the usual way. Both
by instruction and by correction with her hands, the therapist empha-
sizes each move, ensuring that the patient achieves it correctly. Only
when the patient consistently makes a single movement correctly does
the therapist stop correcting that component. The patient needs to
see and feel the correct posture at each move, and therefore constant
repetition is necessary.
Action of the patient
To take a step forward with the left leg
1. Place the right hand forward about half a foot length along the
bar and the left one just in front of the hip joint.
2. Take the weight on the right leg, so that the hip is over the
right foot and the knee and ankle in a vertical line.
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3. With the left shoulder slightly protracted, push on the left
hand and depress the shoulder (Fig. 13.6F, p. 227). The effort
is to lift the leg upwards.
4. As the left leg is lifted, it swings forward to follow the
shoulder. The lift is released when a large enough step has
been made. (Small steps should be taken initially, but the foot
must always land in front of the hand.)
5. Take the weight over the left leg.
6. Move the left hand forward along the bar in preparation for
moving the right leg. Pelvic rotation must be avoided.
The following are possible reasons for an inadequate lift:
some weight remains on the moving leg
the hands are too far forward
the weight may be over the toes and not back over the heels, in
which case the trunk may be hyperextended and the legs
consequently inclined too far forward
insuffi cient depression of the shoulder girdle on the side of the
moving leg
the bars are too high or too low
the lift is not held for suffi cient time to allow the leg to swing
forward.
To take a step backward with the left leg
1. Place the left hand slightly behind the hip joint.
2. Lift the leg and at the same time lean forward on that side.
3. Bend the elbow and flip the leg backwards.
Swing-through gait
This gait requires skilled balance, but it is the fastest and most
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useful.
The therapist
The therapist gives assistance where necessary with her hands
controlling the pelvis until the patient can accurately and slowly
perform the movements. The forward thrust of the pelvis to push the
weight over the feet usually needs to be emphasized.
Action of the patient
1. Place the hands forward along the bars as for the swing-to gait.
2. Lean forward and take the weight on the hands.
3. Push down on the bars, depress the shoulder girdle and lift both
legs. The lift must be sustained until the legs have swung forward
to land the same distance in front of the hands as they were
originally behind. Considerably more effort is required than for
the swing-to gait.
4. As the weight is lifted and the legs swing forward, hyperextend
the hips, extend the head and retract the shoulders.
5. To move the trunk forward over the feet, push on the hands,
extending the elbows and adducting the shoulders. When the
weight is fi rmly on the feet, move the hands along the bars for
the next step.
GAIT TRAINING ON CRUTCHES
Progression is made to crutch walking only when the technique
between the bars is good. The height of the elbow crutches is checked
as for the bars.
The change from walking in bars to crutch walking is considera-
ble, and all patients are initially unstable and fearful. A high degree
of balance skill is essential and this is only achieved with persever-
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ance and much practice.
Balance exercises
Balance on crutches is trained in the same way as when balancing in
the bars (Fig. 13.8A). Resisted work is also given to enable the patient
to gain adequate control over the trunk and pelvis.
Walking on crutches
Swing-to and four-point gaits are taught first and progression is made
to swing-through (Fig. 13.8B, C). Until the new postural sense is
established training is again carried out in front of a mirror.
Progression in the four-point gait may be made by using one bar
and one crutch if preferred. Otherwise, progression is directly onto
two crutches, as there is less tendency to trunk and pelvic rotation.
The technique for each gait is the same as already described for
walking in bars. Much greater skill is required and several weeks of
practice will be needed to acquire the necessary balance and
coordination.
Stairs
Climbing stairs is normally functional for patients with good abdom-
inal muscles. Some young and active patients with lesions between
T6 and T10, with or without a spinal brace, may also become effi -
cient and independent.
Patients can climb the stairs either forwards or backwards. The
forwards technique is usually taught first because it has the advantage
that the patient can see where he is going. Most agile patients with
good abdominal muscles will learn both methods and make their
own choice. Where there is severe abdominal and/or hip flexor spas-
ticity, the degree of hyperextension easily obtainable at the hip joints
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may be too limited for the forwards technique.
Two rails are used initially, progression being made to one rail and
one crutch. Finally, the second crutch must be carried, usually in the
crutch hand, as illustrated in Figure 13.13.
The therapist. The therapist always stands behind the patient. She
holds the trouser band or a therapeutic belt with one hand and grasps
the patient round the waist with the other. After the initial attempts,
both hands should be placed around the pelvis in the usual position
for greater control. Assistance is given, as necessary, until the tech-
nique is mastered.
Forwards technique using one rail and one crutch
To walk upstairs
1. Standing close to the rail, grasp it approximately half a foot
length in front of the toes.
2. Place the right crutch on the stair above, level with the hand
on the rail (Fig. 13.13A). The hands must be level to avoid
trunk rotation when lifting. The tendency to grasp the rail too
far forward and pull must be avoided.
3. Lean over the hands and lift as high as possible, keeping the
trunk and pelvis in the horizontal plane (Fig. 13.13B).
4. As soon as the feet land on the stair above, hyperextend the
hips to find the balance point (Fig. 13.13C).
To walk downstairs
1. Standing close to the rail and keeping the body in the
horizontal plane, place the right crutch close to the edge of the
same stair.
2. Place the left hand down the rail on a level with the crutch
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(Fig. 13.13D).
3. Lift and swing the feet down to the stair below (Fig. 13.13E).
4. Hyperextend the hips and retract the shoulders as soon as the
feet touch the ground (Fig. 13.13F).
Very short patients may need to put the crutch on the stair below
the feet and lift down to the crutch.
Backwards technique using one rail and one crutch
To walk upstairs
1. Balance in hyperextension whilst placing the left hand higher
up the rail and the crutch on the stair above, keeping the
hands level (Fig. 13.13F).
2. Lift backwards (Fig. 13.13E).
3. Regain the balance (Fig. 13.13D).
To walk downstairs
1. Place the crutch on the edge of the same stair as the feet, with
the hands level (Fig. 13.13C).
2. Lift the feet backwards to the edge of the stair.
3. Lean forward on the hands, lift and fl ick the pelvis
backwards (Fig. 13.13B).
4. Drop the feet onto the stair below (Fig. 13.13A).
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